The purpose of this analysis was to determine the most important factors contributing to operative wound infections for patients with head and neck cancer. Four hundred cases were studied prospectively at M. D. Anderson Cancer Center within an 18-month interval. Potential risk factors were categorized based on the patient, the disease, and the treatment. Sixty-three (19.75%) wound infections were recorded. Univariate analysis identified the following factors to significantly alter the incidence of the infection: nutritional status and alcohol consumption (patient factors); T stage and N stage (disease factors); and duration of surgery, type of surgical wound, complexity of the procedure, use of flaps, blood replacement and the use of drains, nasogastric tubes, and tracheostomies (treatment factors). A logistic regression analysis identified the type of surgery, the choice of antibiotic, the presence of concomitant disease, and the N stage to represent the combination of factors most predictive of infection. The initial step toward preventing surgical wound infection is to identify the high-risk factors. The results of this study help to define these parameters so that specific measures can be taken to counteract wound infection.

Purpose: Mycotic pseudoaneurysms (MPA) remain challenging clinical problems. Primary surgical management includes control of hemorrhage and debridement of the infected arterial wall. Because critical ischemia may develop after arterial resection, revascularization has been a secondary goal of treatment. Standard anatomic graft placement or prosthetic bypass grafting has been compromised by a high rate of recurrent infection. Extra-anatomic reconstruction is preferred, with the basic goals being threefold:(1) the use of autogenous graft material to reduce the risk of reinfection; (2) the avoidance of significant size mismatches; and (3) graft placement that is anatomically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals. Methods: In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), common iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Most patients (5 of 7) were known intravenous drug users, who had a painful pulsatile mass in an injection area. Two patients had systemic sepsis, one patient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of duplex/computed tomography scanning and confirmed by means of arteriography in all cases. Results: Obturator bypass grafting was performed by using a reversed deep leg vein in the five femoral MPAs. An ilioiliac, cross-pelvic bypass grafting procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a "pantaloon" aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means of cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications. Conclusion:The superficial femoral/popliteal veins may be particularly useful for limb revascularization in patients with MPAs. This autogenous conduit provides an excellent size-match and a suitable length for reconstruction, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-up is challenging in such cases, but will be required to accurately determine the durability of this strategy.

All patients with PAD in this study had significant reductions in endogenous fibrinolytic activity. Patients with SC had more impaired fibrinolytic activity than those with MC and the control subjects, suggesting that the progression to more severe levels of PAD may be associated with worsening endogenous fibrinolysis.

Reduced systemic fibrinolytic activity ("fibrinolytic shutdown") occurred in these patients after abdominal surgery; it was manifested as increased plasminogen activator inhibitor-1 activity. EPC devices did not enhance systemic fibrinolysis or prevent postoperative shutdown either by decreasing plasminogen activator inhibitor-1 activity or by increasing tissue plasminogen activator activity. These data suggest that EPC devices do not prevent deep venous thrombosis by fibrinolytic enhancement; effective prophylaxis is achieved only when the devices are used in a manner that reduces lower extremity venous stasis.

In this study, enhanced regional fibrinolysis in the lower extremities could not be detected with the use of EPCs, as measured with tPA and PAI-1 activity in common femoral venous blood samples. EPC devices do not appear to prevent DVT with fibrinolytic enhancement; effective and safe prophylaxis is provided only when the devices are used in a manner that reduces lower extremity venous stasis.